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In today’s AMA Update, Mark Linzer, MD, director of the Institute for Professional Worklife at Hennepin Healthcare, talks about the latest research on resident burnout—and specific actions residency program and health system leaders can take to increase well-being. AMA Chief Experience Officer Todd Unger hosts.
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- Mark Linzer, MD, director, Institute for Professional Worklife, Hennepin Healthcare
Unger: Hello and welcome to the AMA Update video and podcast. Today, we're talking about the latest research on resident burnout and specific actions that residency programs and health system leaders can take to increase well-being. I'm joined today by Dr. Mark Linzer, director of the Institute for Professional Worklife at Hennepin Healthcare in Minneapolis. I'm Todd Unger, AMA's chief experience officer in Chicago.
Dr. Linzer, I'm excited to meet you today.
Dr. Linzer: Thank you, Todd. It's a pleasure to be here.
Unger: Well, you're nationally recognized for your research and your thought leadership on professional satisfaction and organizational well-being. How did you get into that field in the first place?
Dr. Linzer: Well, we saw that people were suffering, Todd. There was a malaise in the workplace. There were challenges for teachers, challenges for leaders in internal medicine and other disciplines, and we thought we could get our arms around that with science. And so we did a project for the Robert Wood Johnson Foundation to study 5,000 physicians across the country, and then our work has grown from there.
Unger: Obviously, you've been working with the AMA for a number of years, and the AMA uses your Mini Z measurement instrument in our well-being assessment efforts with health systems and residency programs around the country. I've got a couple important questions. First, why is it called the Mini Z?
Dr. Linzer: The "Z" stands for "Zero Burnout Program," and the "Mini" is because it's small and short and can be done in about two minutes as opposed to most instruments that take 10 minutes.
Unger: OK. So there are larger instruments and this is kind of an abbreviated version, so to speak?
Dr. Linzer: Yes.
Unger: So tell us a little bit more about the Mini Z and how it's been advanced for measuring burnout in residence.
Dr. Linzer: We created the Mini Z from instruments used in the MEMO study, a longitudinal study of primary care practices across the country, to bring a six-page measure down to one page and make it more manageable. Recent studies show it performs very well in measuring in terms of reliability and validity. There's a Mini Z for clinicians, residents, nurses, leaders, other clinical staff. And because burnout is a human phenomenon, we also have versions for teachers, lawyers and workers in general.
It's got 10 items and a few Mini Zs have a five-item add-on for the specific issues of those types of workers. It's been translated into Japanese, Turkish, and Spanish, and is used throughout the world. The core items are three outcomes—satisfaction, stress and burnout—and seven predictors, including the main burnout causes of time pressure and the three Cs—control, chaos and culture—such as values alignment with leaders.
Unger: Now, we know that both the Mini Z and the resident version of the Mini Z have been validated instruments. What's that mean when we talk about "validated"? How is that done? And why should organizations that are looking to measure well-being pay attention to that validation part?
Dr. Linzer: Well, it's important for instruments to be accurate in identifying the issues they seek to measure. So validity is an assessment of whether the instrument is indeed measuring what it purports to measure. So there are various aspects of validity, and thus there are several ways to assess and calculate it. Measures assessed for reliability and validity are preferred.
Unger: Now, we talk a lot about physician burnout here at the AMA, and we know that it is definitely not zero. In fact, it's increased substantially coming out of the pandemic. But specifically today, we're talking about residents. What do you think are the greatest drivers of burnout for residents that come out of your research?
Dr. Linzer: I don't know. A validation piece of the Mini Z for residents, or the Mini Res, and Journal of General Internal Medicine this summer, we found several strong correlates of work conditions with resident burnout, which means there are many ways that programs can address this. These work-life factors included teamwork, control of workload, fast-paced, chaotic environments and time pressure, as well as some resident-specific items of sleep impairment, program recognition of the resident and interruptions.
In our regression analyses, sleep impairment and lack of program recognition seemed especially important. So one of our key findings is that work overload and sleep matter, even in the era of duty hour restrictions.
Unger: So, obviously, those are really key factors. What do you see as faculty's role in this situation to affect these drivers?
Dr. Linzer: I think there's a lot we can do. Evidence-based interventions are usually best. We published our data from Hennepin and academic medicine in 2020 and showed the value of numerous program innovations in keeping burnout at moderate levels, including jeopardy coverage for essential life events, a newsletter celebrating resident achievements, the removal of after-hours consult pager call, an extra day off for senior residents on the wards and care packages distributed through our night teams.
Faculty being on the alert for adverse work environments, such as excess admissions and inability for residents to unplug from the work environment and head home, or in people being distanced on rounds—so they're not really connecting—might prompt faculty to go deeper and discuss with the resident or program director if they can help.
Unger: Now, you recently co-authored a publication on burnout trends. Will you share some of the highlights of that research and whether any of those particular findings surprised you.
Dr. Linzer: Thank you, Todd. We learned so much from this project. We and the country were not, until recently, aware that burnout rates had skyrocketed at the end of 2021 to over 60%, when typically they are at 30% to 40%. This paper you referred to in JAMA Health Forum was in 20,000 clinicians across the country and assess the potential impact of aggravators and mitigators.
Feeling valued was a big mitigator, with burnout rates 30% lower if present. Teamwork was also a big mitigator, while work overload and fast-paced environments were key aggravators. We thus proposed KPIs, or key performance indicators, for organizations to follow to see how they are doing and what work-life factors or work conditions might be addressed to help them improve.
So feeling valued by one's organization had an especially strong relationship with well-being in several of our coping with covert studies. New work by a group is exploring what might contribute to people feeling valued. And, unfortunately, in our studies, less than half of clinicians right now feel valued in medicine. And then, also, you asked about workspaces and chaos.
So workspaces also matter. The physical environment is a key contributor to stress. Ongoing chaos in the environment can be particularly deleterious and workspaces should be assessed for a busy but reasonable ambiance as opposed to ones that are hectic or chaotic, which, unfortunately, arise in close to 40% of primary care practices.
Unger: Wow I had a chance to talk with Dr. Sinsky, too, one of your research partners who works at the AMA, on this topic and she outlined some of those findings, too, in this issue around feeling valued, control over your environment, and also this chaos. You can just imagine that kind of matrix where somebody feels not feeling very valued in a high-chaos environment. That is probably not a quadrant we want to be in, but it sounds like, coming out of a pandemic, we have been there for some time. Is that right?
Dr. Linzer: That is a very, very important observation, Todd.
Unger: Obviously, your research have been incredibly important in understanding this particular topic. What kind of actions have you seen taken, especially by program leaders and residency institutions, in response to the learning? And any kind of specific advice you have for leaders who might be just starting out on trying to improve the situation?
Dr. Linzer: Our main message, which comes from our medicine residency program director at Hennepin, Dr. Rosemary Quirk, is to involve residents in the data review and the interventions. So this is a team effort. Let the team guide what needs to be changed and where to go and then let you know if you got there.
This goes beyond internal medicine. Dr. Ralph Greco, one of my heroes in this field, published his surgery team's work at Stanford in JAMA, describing what they call the Balance for Life program. Everyone can be a part of system change for the betterment of all residents and their patients.
Unger: I'm curious, have you seen health systems leverage this work, especially in the recruitment of residents? Also, what Dr. Sinsky brought up in our conversation was the strain that staffing problems are really driving in the wake of the pandemic.
Dr. Linzer: So two parts. Let me see if I get both. Our perception is that applicants to residency programs are glad to hear when our program takes wellness seriously. So it's a big recruiting tool. Fortunately, there are now a fair amount of data about how to build an infrastructure for wellness, how to measure it, and how to make evidence-based recommendations for change in concert with the residents themselves.
So we are very interested in staffing shortages, and that is one of the next pieces of data we plan to attend to, is how to look across the entire workforce. We have a paper under review that looks at workload and burnout across the health care workforce and doctors, nurses, clinical staff and other staff. This is not an issue that's restricted to clinicians. It's all across the workforce and we need to look at each layer to know how to help everyone.
Unger: Now, a lot of the findings coming out of the Mini Z research say the work that AMA has done to identify the sources of burnout being largely rooted in system-level problems, about 80%, and that has really generated our work and steps forward, the modules on the AMA site, to help address those. Now, when you look at residency programs, are you thinking about redesigning at the system level to address drivers for residents?
Dr. Linzer: I think measurement is critical. My usual advice to organizations is build an infrastructure and then start measuring where you are so you'll know when you made it better. So knowing where you are allows you to determine where you wish to go, and once it gets better, you can then continue to drive improvement through measurement and evidence-based interventions.
Taking the long view, as you suggest, will bring improvements to trainees, faculty and other clinicians, staff and patients. So, really, we've been measuring now for eight years at Hennepin and having successive years of data involving the residents in the change, one by one, making very specific aspects of work-life better is what this takes. And I've seen so many residency program directors who are so good at this. I'm very optimistic.
Unger: Anything that we should be on the lookout for in terms of research in 2023?
Dr. Linzer: We have several works in progress. We have the paper I mentioned on burnout across the health care workforce. We have one on what constitutes feeling valued so people know how to give value to their workers, another on burnout drivers in hospital medicine and another on meeting the challenges that face primary care. We are planning one on staffing shortages that you mentioned as well.
And then, finally, we have a new focus on moral injury as a preventable source of burnout and are rolling out and testing metrics and interventions for that work.
Unger: Well, thank you so much, Dr. Linzer, for being with us today and for your continuing work in this important area. For everybody listening out there, the Mini Z assessment and this kind of benchmarking that Dr. Linzer is talking about, critical offering of our programs at the AMA for health systems and residency institutions. And I urge you to reach out to the AMA and find out how those could benefit your physicians and residents in your program.
That's it for today's episode. We'll be back with another episode shortly. You can catch all our podcasts and videos at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.